Patient History Form

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Home » Patient History Form

MEDICAL HISTORY QUESTIONNAIRE

Please answer all the questions below to the best of your ability. Our ability to help you is based, in part, upon the accuracy and completeness of your medical/ophthalmic history and description of symptoms.

Name
First Last
Date
MM slash DD slash YYYY
Date of Birth
MM slash DD slash YYYY
How would you like us to address you?
Home Phone
Work Phone
Cell Phone
Address
Street Address Address Line 2 City State ZIP Code
Social Security #
Email
Occupation
Employer
How did you hear of our office?
- Insurance plan
- Family member
- Internet
- Other
OR referred by:
May we send them a thank you note?
Please list any members of your family who come to our office:
Chief reason(s) for visit:
Special visual demands (at work/sports/hobbies):
Are you interested in getting new eyeglasses today?
Preliminary Medical History
Do you have any allergies to medications?
- Yes
- No
Explain:
Please list major injuries and/or surgeries you have had:
Who is your primary care physician (internist/family doctor)?
Are you pregnant and/or nursing?
- Yes
- No
Please note any personal or FAMILY HISTORY (parents or siblings only; living or deceased) with the following:
No Self Parent Siblings Uncertain
Cataract
Crossed Eyes
Glaucoma
Macular Degeneration
Retinal Detachment/disease
Other
If other, please specify:
Social History:
Do you drive?
- Yes
- No
Have you had visual difficulty when driving?
- Yes
- No
Do you use tobacco products?
- Yes
- No
How long?
Review of Systems

Do you currently or have you ever had any problems in the following areas:

	Yes	No	Uncertain
Fever, Weight Loss/ Gain
Integumentary (skin)
Headaches
Migraines
Loss of Vision
Double vision
Dryness
Itching
Excess tearing
Infection of eye lid
Chalazion/ stye
Flashes/Floaters
Thyroid Disease
Diabetes
Psychiatric
Lupus/other autoimmune
Allergies / Hay fever
Dry throat and/or mouth
Asthma
COPD / breathing problem
High Blood Pressure
Other vascular disease
Rheumatoid Arthritis
Joint Pain
Anemia
Bleeding Problems
Cancer
Other

If cancer, please specify:
Type Status
If other, please specify:
For ‘Yes’ answers to any of the above or if you have a condition not listed, please explain.
List all drugs you are taking including aspirin, oral contraceptives, hormones, over the counter meds or vitamins:
Maintaining the privacy of your information is of paramount importance to us as it helps foster confidence, good will and stronger relationships with you, our patients. If, at any time, you have questions or concerns about our privacy practices, please feel free to read our Notice of Privacy Practices.
If you have any questions, please feel free to contact us at frontdesk@madisoneyesnj.com. Copies of this Notice are also available upon request.
By initialing your name, you agree that you understand our Notice of Privacy Practices/HIPPA
I have carefully completed this questionnaire to the best of my ability. I understand that my doctor’s ability to best care for me (or child) is based significantly on the family/personal health history and description of symptoms.
Patient/Guardian Signature
Date
MM slash DD slash YYYY
Doctor’s Signature (after reviewing)
Date
MM slash DD slash YYYY
Optos Ultra-Wide Retinal Imaging
During the COVID-19 emergency, we are requiring a retinal screening as part of a comprehensive eye exam for these reasons:
- We are usually able to safely and comfortably examine the interior of your eyes without using dilating eye drops while improving social distancing.
- We are able to detect eye diseases at an early stage, even before the onset of symptoms. In some cases we will also recommend a dilation of your pupils. There will not be any additional fee charged for pupil dilation.
- It is much faster than a dilated exam without the annoyance of eye drops or an extended exam with especially bright instrument lights. There isn't blurred or light sensitive vision afterwards.
- We maintain permanent images to identify change.
- We are able to detect and manage eye diseases with documentation of change or stability.
While the instrument is expensive, we are able to keep the screening fee affordable at $39.
Please confirm your acceptance of receiving retinal imaging, below.*
- Yes, please include the retinal imaging as part of my (or my child's) exam. I understand that there is a fee of $39 that is not covered by my insurance plan.
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First Last
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Signature:
Date:
MM slash DD slash YYYY
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Madison Eyes

311 Main Street
Madison, NJ 07940-2338

Phone: 973-377-1060
Fax: 973-660-1133

Monday: 9:00 AM - 6:00 PM
Tuesday: 9:00 AM - 7:00 PM
Wednesday: 8:00 AM - 7:00 PM
Thursday: 9:00 AM - 6:00 PM
Friday: 8:00 AM - 4:30 PM
Saturday: 9:00 AM - 2:00 PM
Sunday: Closed

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Madison Eyes
311 Main Street
Madison, NJ 07940-2338
Phone: 973-377-1060
https://www.madisoneyesnj.com

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